Trust Chief ‘strongly criticised’ for not telling family of report

The former Chief Executive of the now defunct Sperrin Lakeland Trust, Mr Hugh Mills, has been “strongly criticised” for the failure to disclose an important report to the Western Health Board about the death of a child in the Erne Hospital.

In the findings of a public inquiry into the deaths of five children in hospitals in Northern Ireland, the chairman, Mr. Justice John O’Hara names a number of doctors and health service directors and managers, and he outlines the role they played following the death of 17-month-old Lucy Crawford in April 2000.

Among the volumes of Mr. O’Hara’s reports on all deaths, there is a 96-page section on what happened after Lucy died at the Erne.

She had been admitted with a routine tummy bug and put on a drip due to being dehydrated after vomiting.

But serious errors with her fluid management resulted in her suddenly collapsing and dying after being transferred to the Royal Hospital in Belfast.

The report includes criticism of the way the Crawford family was treated.

Mr. O’Hara says that the consultant in charge of her case, Dr. Jarleth O’Donohoe was “unprofessional in his approach” when meeting the family, and the Judge says: “Dr. O’Donohoe had a duty to explain fully what he knew to have happened,” and when the doctor didn’t advise the family about a review that had been held, the report says: “That they were not so advised raises the concern that the issues were deliberately withheld so as to avoid blame and criticism.”

Mr. O’Donohoe met the Crawfords weeks after the child’s death and claimed he “did not know” how she died; but the inquiry report shows that fluid mismanagement was discussed by several clinicians and managers at a very early stage of her treatment.

The chairman said some of Dr. O’Donohoe’s explanations to the inquiry were “implausible and bizarre.”

In Sperrin Lakeland Trust investigations afterwards, a number of reports were drawn up but were concealed from the family and the Coroner.

One of the reports was conducted by the Royal College into the overall conduct and competence of Dr. O’Donohoe in Lucy’s case and four others.

Mr O’Hara says: “I am left to consider the motivation for such deliberate non-disclosure to the next of kin. The obvious explanation is that they were deliberately withheld to keep from the Crawford family the known connection between medical mismanagement and the death of their daughter.”

The chairman goes on to say: “Regrettably, I must find that the Trust’s engagement with them was reluctant, incomplete, defensive and misleading. The Chief Executive must bear responsibility for this failing.”

And referring specifically to Sperrin’s failure to disclose a Royal College report to either the Western Health Board or the Crawford family, Mr. O’Hara says: “Mr. Mills is to be strongly criticised for this failure.”

Mr. O’Hara’s inquiry was set up in 2004 by the then Direct Rule Health Minister, Angela Smyth and initially included the deaths of five children, including Lucy.

In 2008, the Crawford family requested “for personal reasons” that the circumstances of her death be removed from the inquiry.

Mr. O’Hara agreed to their request, but said he was compelled to continue with what happened in the aftermath to discover what relevance it had to the death of another child, Raychel Ferguson in the Altnagelvin Hosptial in Derry the following year.

Mr. O’Hara concludes that no lessons were learned about Lucy’s death and a number of things were concealed by clinicians and managers.

The findings begin the night of Lucy’s treatment in the Erne and continue through the Royal’s signing of a death certificate which “made no sense” and go on to look at the actions of Trust management.

He concludes that the poor care received by Lucy was “deliberately concealed….from the family, the Coroner and the pathologist.”

“The failure by senior clinicians to address the issue with appropriate candour suppressed the truth…

He cites “a determination to protect professional colleagues.”

On the night she was admitted and put on a drip, the inquiry says mistakes were made with the type of solution she was given and that she was given far too much.

The report says Dr. O’Donohoe should have communicated his instructions “in clear and certain terms” to other staff.

The doctor later told the PSNI when questioned that he was called and reduced the level of fluid.

“However,” says Mr. O’Hara, “if he did, the change was not recorded and is contradicted by Staff Nurse MacNeill.”

But he describes this as “academic” because “Lucy was already critically overloaded with fluid.”

Dr. Thomas Auterson, consultant anaesthetist, was called and managed to intubate her, but believes she was “already beyond help.”

Nevertheless, Drs. O’Donohoe and Auterson agreed to send Lucy to the Royal to see if they could do anything for her.

“Disconcertingly,” says Mr. O’Hara, “the clinicians do not appear to have been curious as to why a moderately dehydrated patient should suffer a significant decline…….”

After Lucy’s transfer to the Royal, there was further discussion about her fluid management, when Dr. Peter Crean rang Dr. O’Donohoe to ask about it.

Dr. Auterson has stated that even when he was attending Lucy, he reached the conclusion that she had been given too much of the wrong fluid, and described it as a “strong suspicion” on the morning of Lucy’s deterioration.

In the day or two after her death, he discussed this with Dr. Matt Cody, who agreed with his suspicion, and he discussed the case with Dr. William Holmes “who did not disagree.”

However, Dr Auterson did not volunteer this opinion when he made a statement to the Erne Hospital Review.

Dr. Auterson believed Dr. O’Donohoe was aware of his suspicions. “It was the elephant in the room. Why did nobody else come to this conclusion?”

But Dr. O’Donohoe has disputed Dr. Auterson’s account.

The O’Hara report says: “I do not accept that the cause of death could not have been established promptly and accurately. It could and should have been established almost immediately because Dr. Auterson was not alone in forming this suspicion.”

Another consultant, Dr. Mohammed Asghar wrote in June to the Chief Executive, Mr. Mills saying: “This child might have been given excess of fluids.”

Mr. O’Hara says: “Dr. Asghar had no difficulty in recognising mismanagement of fluids….. His curiosity and desire to do the right thing stand in commendable contrast to those of his colleagues.”

The detailed report goes on to outline and discuss the roles played in Lucy’s treatment and the investigation of it by Sperrin Lakeland Trust, including Dr. James Kelly, the Medical Director who was made of aware of fluid management issues by a Royal College doctor.

Mr. Eugene Fee and Dr. Trevor Anderson were also involved in a review of the case.

All of Mr. O’Hara’s findings on Lucy Crawford and all the other children, and a statement by him are published on the inquiry website http://www.ihrdni.org/inquiry-report.htm

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